Refer a Patient

Dental Specialists of Central Ohio was created with a dream of providing all your specialty dental needs in one easy to access location without losing the personal approach our specialists provide.

Please fill out the following form if you are referring a patient to one of your specialist.

Referral Form

Patient Name
*

First

Last
*

Last

Patient Phone
*

Referred by Name
*

Referred by Phone
*

Specialty Need
*

Description of Services Requested/Comments/Chief Concern:
*

Please select upper tooth/teeth needing treatment:
*

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

None

Please select lower tooth/teeth needing treatment:
*

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

None

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Additional Notes:

(740) 913-0328

At Dental Specialists of Central Ohio, we strive to provide every family member the most comprehensive, quality Specialty Dental Care in one convenient location. Our services range from Pediatric Dentistry, Orthodontics, Periodontics, Oral Surgery, Sleep Apnea/TMJD and Endodontics.